Conlon P J, Stafford-Smith M, White W D, Newman M F, King S, Winn M P, Landolfo K
Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
Nephrol Dial Transplant. 1999 May;14(5):1158-62. doi: 10.1093/ndt/14.5.1158.
Acute renal failure requiring dialysis (ARF-D) occurs in 1.5% of patients following cardiac surgery, and remains a cause of major morbidity and mortality. While some preoperative risk factors have been characterized, the influence of preoperative and intraoperative factors on the occurrence of ARF following cardiac surgery is less well understood.
Preoperative and intraoperative data on 2843 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) from February 1, 1995 to February 1, 1997 were recorded and entered into a computerized database. Two definitions of renal failure were employed: (i) ARF defined as a rise in serum creatinine (Cr) of 1 mg/dl above baseline; and (ii) ARF-D defined as the development of ARF for which some form of dialytic therapy was required. The association between preoperative and intraoperative variables and the development of ARF was assessed by multivariate logistic regression.
A total of 2672 of the 2844 patients underwent isolated coronary artery bypass grafting (CABG) surgery, the remaining 172 underwent valve surgery with or without bypass grafting. Of the CABG patients 7.9% developed ARF and 0.7% developed ARF-D. The mortality for patients who developed ARF was 14% (OR 15, P = 0.0001) compared with 1% among those who did not develop ARF. The mortality for CABG patients who developed ARF-D was 28% (OR 20, P = 0.0001) compared with 1.8% among those who did not require dialysis. Variables that were significantly associated with the development of ARF by multivariate analysis included: increased age, elevated preoperative serum Cr, duration of CPB, presence of a carotid artery bruit, presence of diabetes, reduced cardiac ejection fraction and increased body weight. Variables independently associated with ARF-D included serum Cr, duration of CPB, carotid artery bruit and presence of diabetes. The utility of these models for predicting the development of ARF and ARF-D was confirmed by bootstrapping techniques. Because of the small number of patients who underwent valve surgery, none of these variables were significantly associated with the development of ARF or ARF-D in this group of patients.
The development of ARF or ARF-D is associated with a high mortality following CABG surgery. We have identified perioperative variables, which may be useful in stratifying risk for the development of ARF.
心脏手术后1.5%的患者会发生需要透析的急性肾衰竭（ARF-D），它仍是主要的发病和死亡原因。虽然一些术前危险因素已得到明确，但术前和术中因素对心脏手术后ARF发生的影响仍了解较少。
记录了1995年2月1日至1997年2月1日连续2843例接受体外循环（CPB）心脏手术的成年患者的术前和术中数据，并录入计算机数据库。采用了两种肾衰竭的定义：（i）ARF定义为血清肌酐（Cr）较基线水平升高1mg/dl；（ii）ARF-D定义为需要某种形式透析治疗的ARF。通过多因素逻辑回归评估术前和术中变量与ARF发生之间的关联。
2844例患者中共有2672例接受了单纯冠状动脉旁路移植术（CABG），其余172例接受了有或无旁路移植的瓣膜手术。在CABG患者中，7.9%发生了ARF，0.7%发生了ARF-D。发生ARF的患者死亡率为14%（比值比15，P = 0.0001），而未发生ARF的患者死亡率为1%。发生ARF-D的CABG患者死亡率为28%（比值比20，P = 0.0001），而不需要透析的患者死亡率为1.8%。多因素分析显示与ARF发生显著相关的变量包括：年龄增加、术前血清Cr升高、CPB持续时间、颈动脉杂音、糖尿病、心脏射血分数降低和体重增加。与ARF-D独立相关的变量包括血清Cr、CPB持续时间、颈动脉杂音和糖尿病。这些模型预测ARF和ARF-D发生的效用通过自抽样技术得到了证实。由于接受瓣膜手术的患者数量较少，在这组患者中这些变量均与ARF或ARF-D的发生无显著关联。
ARF或ARF-D的发生与CABG手术后的高死亡率相关。我们已经确定了围手术期变量，这些变量可能有助于对ARF发生的风险进行分层。
